Provider Demographics
NPI:1518069160
Name:LONGMIRE, KIMBERLY A (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:LONGMIRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD.
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-605-7171
Mailing Address - Fax:
Practice Address - Street 1:15025 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3409
Practice Address - Country:US
Practice Address - Phone:858-605-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52306207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A523060Medicaid
WA52306BMedicare PIN
00A523060OtherBLUE SHIELD OF CA
CAG76564Medicare UPIN
B202OtherCHAMPUS
CA00A523060Medicaid